Signed Package

Payment Receipt 4603 Broadway Ste B
Sacramento CA 95820
New Business Phone : 111-111-1111
Transaction #30470400 License # 6002326
New Business #17283628 Office : 1310
Carlos Murguia Customer #15348569

3701 Branch St Received By: Gabriela Rizo
Sacramento CA 95838-3429 Print Date/Time : 6/25/2021 2:57 PM PDT
Fees
Added Date Type Description Amount
6/25/2021 Automobile Insurance Down Payment to Carrier $189.83
6/25/2021 Documentation Fees Documentation and Imaging Fee $25.00
6/25/2021 Broker Fee Broker Fee $85.17
6/25/2021 Convenience Fee Convenience Fee $20.00
Total Fees: $320.00

Received Payments
Received Date Type Description Credit Card # / Check # / Other Amount

6/25/2021 None- $320.00
NoCoverageUntilPaid
Total Amount Received : $320.00
TOTAL PAYMENT : $320.00
Customer Service: (800) 300-0227
Policy Number: GPSV-00166950-00 Insurance Company: Aspire General Insurance Services
Note: For Credit Card and Electronic Check Payments (AHC) charges will appear on your statement as FREEWAY INSURANCE CA
** If the Received Payments Type above indicates "None - No Coverage Until Paid ", then no payment has been
received and this document is not evidence of coverage or receipt of payment. **
Customer Signature: Agent Signature:
BIG SAVINGS!
Find out more about our additional products:
• Auto • Motorcycle • Home • Small Commercial Auto • Hospital Indemnity
• Renter’s • Identity Theft • Telemedicine
Ask your agent or call: 888-253-0674
Page 1
Carlos Murguia eSign: 6/25/2021 3:18 PM PDT, IP: 2600:387:f:4b10::2
Broker Report
Broker: Gabriela Rizo

Transaction Number: 30470400
Transaction Date: 6/25/2021
Office: 1310 Sacramento-Broadway
Customer Name: Carlos Murguia

Customer DOB: 1/10/1983
Address: 3701 Branch St
Sacramento, CA 95838
(760) 590-5887
Carrier Name: Aspire General Insurance Services / ________

Policy Number: GPSV-00166950-00
Policy Terms: 1 Year
Policy Type: Personal: Auto
Premium Amount: $2,085.00
Effective Date: 6/25/2021
Expiration Date: 6/25/2022
#GPSV- Aspire General Insurance

00166950-00 Services
Year Make Model
▪ 2003 GMC YUKON
▪ 2003 MITSUBISHI MONTERO SPORT XLS
▪ 2015 NISSAN VERSA S
#GPSV-00166950-00 Aspire General

Insurance
Services
Name Birth Date License Number
▪ Carlos Murguia 01/10/1983 D6929884 / CA
▪ Rocio Ochoa 05/02/1986 d5695298 / CA
Submit Amount: $189.83
By submitting this report and customer application, Broker 1) is aware of Company policy
concerning unauthorized rewrites, and 2) understands and agrees that any dishonesty or deception
involved in rewriting this customer is fraud, and will result in loss of commissions and possible
Page 2
disciplinary action, up to and including termination.
Page 3
INSURANCE 101 - GENERAL COVERAGE DESCRIPTION FORM
There are many coverage options available to you as a consumer. It is important that you select coverage that meets your
needs. Please select the appropriate coverage. This is for educational purposes only. Please refer to the paperwork provided by
your insurance carrier for specific information concerning your policy.
Selected Carrier: Aspire General Insurance Services/________

_______________________________________________________________________________________________________
Bodily Injury Liability: This coverage is required by law to protect other people when you are at fault. It does not protect you
or your property. In the event of an auto accident, this will cover medical expenses for the other drivers and passengers up to
the selected limits.
Limit Per Person: 15,000 / Limit Per Accident: 30,000
□ I decline all Bodily Injury Liability coverage.
_______________________________________________________________________________________________________
Property Damage Liability: This coverage is required by law to protect the property of other people when you are at fault. It
does not protect you or your property. In the event of an auto accident, this will cover expenses for the property of other
people up to the selected limits.
Property Damage - Limit: 10,000
_______________________________________________________________________________________________________
**If you select basic minimum bodily injury and property damage liability coverage, you may qualify for the State’s Low Cost
Auto Insurance program ($10,000/$20,000/$3,000) through the California Automobile Assigned Risk Plan at (866) 602-8861 or
by visiting www.mylowcostauto.com. Among other conditions, applicants must be continuously licensed drivers for the past
three years, must qualify as “Good Drivers,” have vehicles valued not more than $25,000 & the household gross annual income
must be 250% or less of the federal poverty level.
_______________________________________________________________________________________________________
Uninsured/Underinsured Motorist Bodily Injury: This optional coverage protects you and your passengers when you are not
at fault. In the event of an auto accident with an identified uninsured or underinsured driver, this will cover medical expenses
for you and your passengers up to the selected limits. This coverage can be combined with Medical Payments coverage for
additional protection for you and your passengers.
Limit Per Person: 15,000 / N/A
Limit Per Accident: 30,000 / N/A
_______________________________________________________________________________________________________
Uninsured/Underinsured Property Damage with Collision Deductible Waiver: This optional coverage protects your property
when you are not at fault. In the event of an auto accident with an identified uninsured or underinsured driver, this will cover
expenses for your vehicle up to the selected limits. You will not pay a deductible for this coverage.
Property Damage: N/A
□ I decline all Uninsured/Underinsured Property Damage coverage.
_______________________________________________________________________________________________________
Medical Payments: This optional coverage protects you and your passengers regardless of fault. In the event of an auto
accident, medical payments coverage will pay for reasonable medical and/or funeral expenses for you or any other person in
your vehicle up to the selected limits. This coverage can be combined with Uninsured/Underinsured Motorist coverage for
additional protection if you are involved in an auto accident with a negligent uninsured/underinsured driver.
Medical Payments - Limit: N/A
□ I decline all Medical Payments coverage.
_______________________________________________________________________________________________________
Comprehensive: This coverage protects your property. If your vehicle or its factory installed equipment are damaged by fire,
theft, vandalism, or other events (other than a collision), this coverage will pay for all necessary repairs to your property once
the selected deductible is paid. This protection may be required by a lender or lienholder.
Comprehensive Deductibles:
Vehicle 1: GMC YUKON Deductible $500

Vehicle 2: MITSUBISHI MONTERO Deductible $0
SPORT XLS
Vehicle 3: NISSAN VERSA S Deductible $500
Page 4
Vehicle 1: St
3701 Branch GMC YUKON Deductible $500
Received By: Gabriela Rizo
Vehicle 2: CA
Sacramento MITSUBISHI
95838-3429 MONTERO Deductible $0Print Date/Time : 6/25/2021 2:57 PM PDT
SPORT XLS
□ I decline all Comprehensive coverage.

_______________________________________________________________________________________________________
Collision: This coverage protects your property. In the event of a collision with any vehicle or other object, this coverage will
pay for all necessary repairs to your vehicle once the selected deductible is paid. This protection may be required by a lender
or lienholder.
Collision Deductibles:
Vehicle 1: GMC YUKON Deductible $500

Vehicle 2: MITSUBISHI MONTERO Deductible $0
SPORT XLS
□ I decline all Collision coverage.

_______________________________________________________________________________________________________
Special Equipment Coverage: This coverage protects your property up to the selected limits. You will need receipts and photos
taken of the items listed when the coverage begins.
Special Equipment Limits:
Vehicle 1: GMC YUKON Limit N/A

Vehicle 2: MITSUBISHI MONTERO Limit N/A
SPORT XLS
Vehicle 3: NISSAN VERSA S Limit N/A
□ I decline all Special Equipment coverage.

_______________________________________________________________________________________________________
Rental Reimbursement: This coverage is only available on vehicles with Comprehensive and Collision coverage. If you need to
rent a car, you will be reimbursed for the rental up to the selected limits and timeframe.
Rental Limits and Timeframes:
Vehicle 1: GMC YUKON Limit N/A

Vehicle 2: MITSUBISHI MONTERO Limit N/A
SPORT XLS
Vehicle 3: NISSAN VERSA S Limit N/A
□ I decline all Rental Reimbursement.

_______________________________________________________________________________________________________
Roadside Assistance: This coverage provides roadside assistance and is available on many different programs. We can provide
more details based on your selected program.
N/A
□ I decline all Roadside Assistance.
_______________________________________________________________________________________________________
Customer Signature: Date: 6/25/2021

Name Printed: Carlos Murguia
Page 5
Freeway Insurance Services America, LLC (California).

(License No. 6002326)
PROMISE TO PROVIDE AGREEMENT
I am seeking to obtain insurance coverage effective 6/25/2021 , but I do not have the following information with me, which is
necessary in order to complete my transaction:
Due Date
▪ Valid California driver's license for 7/16/2021
Drivers
Driver 1: Carlos Murguia ; Driver 2: Rocio Ochoa
▪ Valid vehicle registration for 7/16/2021
Vehicles
Vehicle 1: 2003 GMC YUKON ; Vehicle 2: 2003 MITSUBISHI MONTERO SPORT XLS ; Vehicle 3: 2015
NISSAN VERSA S
I will provide the indicated information on the date stated above.
In the event that the information is not provided by the above date, I understand that some or all of my coverage may be subject
to a premium increase, cancellation, or rejection, with no coverage in effect. I also understand that if this occurs, I may lose all
or part of my down payment and fully-earned Broker Fee, and I may incur other financial loss.
AGREED TO BY : DATE: 6/25/2021

NAMED INSURED'S SIGNATURE ONLY
NAMED INSURED: Carlos Murguia

DRIVERS LICENSE: D6929884
HOME PHONE: (760) 590-5887
AGENT: Gabriela Rizo
OFFICE: 1310 Sacramento-Broadway
AUTHORIZED BY:________________________________ DATE: _____________________
MAIL Information to: FAX Information to:

Freeway Insurance Services America, LLC (California). Freeway Insurance
Services America, LLC (California).
7711 Center Ave. #200 processing@freewayinsurance.com.
Huntington Beach, CA 92647 FAX: (714) 252-2606
ATTN: Customer Service Dept. ATTN: Customer Service Dept
CUSTOMER SERVICE TELEPHONE NUMBER (800) 300-0227

7711 Center Ave. #200• Huntington Beach, CA 92647 • TEL (800) 300-0227 • FAX (714) 252-2606
Page 6
BROKER FEE DISCLOSURE FORM
This disclosure was prepared by the California Insurance Commissioner.

Please READ IT CAREFULLY!
I. Do not sign any broker fee agreement unless all of its blank lines and spaces have been filled-
in and you have read the entire document and the agreement carefully.
II. Your insurance broker represents you, the consumer, and is entitled to charge a broker fee if
he/she chooses. This fee is not set by law, and may be negotiable between you and the broker.
III. It is illegal for an insurance broker to charge you a fee for placing coverage solely with the
California Automobile Assigned Risk Plan or the California Fair Plan. Fees may be charged for
placement of other coverages.
IV. Broker fees are often non-refundable even if you cancel your coverage. Refer to your broker
fee agreement to see if your broker fee is non-refundable. However, you may be entitled to a full
refund of a broker fee if your broker acted incompetently or dishonestly. Unresolved disputes over
non-refunded broker fees can be forwarded to the Department of Insurance for review.
V. You are entitled to obtain and keep a completed copy of this disclosure and any broker fee
agreement you sign.
VI. Your broker may receive a commission from insurance company (ies) for placing your
insurance. This commission may be paid to your broker by the insurance company (ies) in addition to
any broker fee you pay.
VII. If you will be paying your premium in installments to a finance company, by law you must
receive a copy of a premium finance disclosure and agreement. Be sure to obtain and read those
documents before signing a premium finance agreement. Also, ask the broker if the insurer offers its
own installment payment plan. Insurer installment plans are often cheaper than premium financing
through a separate premium finance company.
VIII. If your broker is placing automobile coverage, your broker must provide you with a copy of
the current Department of Insurance pamphlet “Automobile Insurance.” If your broker is placing
residential coverage, your broker must provide you with a copy of the current Department of
Insurance pamphlet “Residential Insurance.” By signing this disclosure, you acknowledge receipt of
the appropriate pamphlet(s).
Client Initials:
Page 7
Freeway Insurance Services America, LLC (California).

(License No. 6002326)
BROKER FEE AGREEMENT
APPOINTMENT OF INSURANCE BROKER and AGREEMENT TO PAY BROKER FEE
As of 6/25/2021, the undersigned (Client) appoints Freeway Insurance Services America, LLC (California)., (Broker and us) as his/her insurance broker of
record . This Agreement shall continue in full force until terminated by either party. Broker agrees to represent Client honestly and competently in obtaining
and servicing the desired insurance coverages, as may be available. Client agrees to act in good faith with Broker. For each non-Assigned Risk policy, Client
agrees to pay a broker fee for Broker's services, as specified below. This broker fee is in addition to any commissions paid, if at all, to Broker by an insurance
company.
Included in the estimated cost is a Broker Fee of $85.17 for Automobile policy or for Renter's policy . . Client agrees to this fee and fully understands that the
broker fee is / is not refundable , including if the insurance is cancelled or rejected. Broker and Client agree to the following additional fees, if applicable: (1)
Processing the request for reinstatement of a cancelled policy - $100.00 fee, (2) Processing Endorsements - $100.00 fee, (3) Accepting and processing of
monthly premium payments - $10.00 fee, (4) A non-refundable Document Imaging/Storage Fee of Client’s documentation - $25.00, and (5) A non-refundable
fee to process and handle “split” down payments - $15.00, and (6) A non-refundable $20.00 Convenience Fee to electronically conduct a new business
application. Client authorizes Broker to maintain premium payments in interest-bearing trust accounts, and to receive any interest income therefrom, until
paid to the insurance company.
CANCELLATION AND OTHER MISCELLANEOUS PROVISIONS
Cancellation. Client agrees that all cancellation request(s) or changes to the policy, of any kind, must be in writing to be processed by Broker . In the event
that any changes to the policy result in additional fees or premium, Client acknowledges that he/she is responsible for same. In the event that Broker provides
Client an insurance Identification Card, Client acknowledges and understands that insurance coverage is not provided until the application is underwritten and
accepted by the insurance company. According to the State of California, the Identification Card cannot be used as proof of insurance until the insurance
company has accepted and issued coverage as evidenced by a declarations page and/or policy. Client further agrees and understands that the choice of
coverage(s) and limits of liability is that of the Client and not of the Broker,and as such, Broker is not responsible for the adequacy of coverage(s) and/or limits
of liability. Finally, Broker and Client agree that venue for any and all small claims actions between the parties shall exclusively reside in the Santa Ana Court,
Orange County, California.
Effective Date . Client understands and acknowledges that the effective date of the policy(ies) may differ from the date stipulated in this Agreement and can be
obtained from the insurance company application. Client agrees to the conditions set forth above and acknowledges receipt of a copy of this Agreement.
Client understands that upon signing this document, the broker fee will be fully earned by Broker and will not be refunded even if the policy is cancelled.
Communications Consent and Telephone Monitoring . By providing the number of a land line, cell phone or other wireless device, Client expressly consents
and authorizes us and any of our Affiliates, agents, service providers or assignees to: (i) call you using an automatic telephone dialing system or otherwise; (ii)
leave a voice, prerecorded, or artificial voice message for Client; and/or (iii) send Client a text or other electronic message for any purpose related to the
servicing or collection of the Policy or for other transactional or informational purposes related to the Policy (each a “Communication”). Client agrees that we
and any of our affiliates, agents, service providers or assignees may call or text Client at any telephone number associated with Client’s Policy, including cellular
telephone numbers, which Client provides to us, now or in the future. Client also agrees that we and any of our Affiliates, agents, service providers or
assignees may include Client’s personal information in a Communication. We will not charge Client for a Communication, but Client’s service provider may. In
addition, Client understands and agrees we and any of our Affiliates, agents, service providers or assignees may communicate with Client in any lawful manner
that does not require prior consent. Client agrees that we may monitor and record any telephone calls to assure the quality of our service or for other reasons.
Client also agrees that no additional notice or approval is needed for any call monitoring or recording.
Consent to Receive Telemarketing Calls and Text Messages . By signing this Agreement, Client authorizes us and any of our Affiliates, agents, service providers
or assignees to deliver telemarketing calls and text messages to the following telephone number(s) (760) 590-5887, and (760) 590-5887 or to any additional or
alternate phone number that the Client may provide, in connection with their application or otherwise, using an automatic telephone dialing system and/or a
prerecorded or artificial voice message. These telemarketing calls and text messages include communications required to complete the purchase and ensure
the effectiveness of Client’s desired insurance coverages. Client understands that this authorization is not required as a condition of purchasing any property,
goods or services. If Client would not like to receive telemarketing calls and text messages using an automatic telephone dialing system and/or a
prerecorded or artificial voice message, please do not sign this Agreement and ask to receive a copy of the Broker Fee Agreement without this provision.
“Affiliated Companies” or “Affiliates.” Please see the enclosed Privacy or Affiliation Disclosure or our website for a list of our Affiliates.
6/25/2021
Insured's Signature Date
Insured Name: _______________________________________________________________________________________________

(Please Print) Last Name First Name Middle I.
6/25/2021
BROKER’S Signature Date
For general customer service questions, please call (888) 300-0227

For unresolved issues and complaints only, please call 800-960-0036 or email us at comments@insuranceservices.pro.
For questions/problems concerning broker fees or insurance, you may contact the Dept. of Insurance at (800) 927-HELP.
7711 Center Avenue, Suite 200, Huntington Beach, CA 92647 • TEL (800) 300-0227 • FAX (714) 252-2606
Page 8
LIVERY (UBER – LYFT – RIDE SERVICE)
AND FOR-HIRE (DELIVERY/Pick-Up) DISCLOSURE
Policy #: GPSV-00166950-00
I, Carlos Murguia hereby acknowledge that neither myself nor anyone who is intended to be a covered driver (or
permissive user) under this policy uses the vehicle(s) disclosed on the application (or any other vehicle added at a
later date) for any:
a) For-Hire ride or driving service, including but not limited to UBER, RIDE, LYFT,TAXI, LIMOUSINE, or similar
Shuttle or Ride-For-Hire or Ride Share service.
b) Delivering or picking up property, goods, or products, INCLUDING BUT NOT LIMITED TO pizza, documents,
newspapers, food, flowers, equipment, supplies, or consumer products;
Failure to accurately attest to the foregoing may lead to your policy being cancelled or coverage/claims being
denied. Customer must also inform the insurance carrier or Freeway immediately upon engaging in the above
services.
Signed and acknowledged this ____________ day of ___________, ______________
Customer Signature
Page 9
IMPORTANT PRIVACY CHOICES

FOR CALIFORNIA CONSUMERS
You have the right to restrict the sharing of personal and financial information with our affiliates (companies we own or
control) and with outside companies with which we do business.
• Please read the enclosed information carefully before you make your choices
• You may exercise your rights at any time
• Please keep these documents for your records
To exercise your privacy rights, you may use the enclosed forms or you may visit us at http://privacychoices.confie.com.
Page 10
Rev. June 2019
IMPORTANT PRIVACY CHOICES

For Residents of California
Protecting the privacy and confidentiality of information about our customers is very important to Freeway Insurance Services
America, LLC . dba Cost-U-Less Insurance Center dba Speedlane Insurance Services, SSB Insurance Services, Inc. dba
Seguros Sin Barreras Insurance Services, InsureOne Insurance Services America dba Buschbach Insurance Agency, dba
Western Sage Insurance Agency, dba California Insurance Specialists, dba Wm K Lyons Insurance Agency, (collectively “we,”
“our” or “us”). This Privacy Notice describes the types of information about you that we collect, where we get it, and how we
use, share and protect it. Our practices are the same for applicants, customers, and former customers. This Privacy Notice
applies to residents of California who obtain insurance products or services for personal, family, or household purposes. The
rights of California residents are not limited by any other privacy notice we may issue.
INFORMATION WE COLLECT
We collect information about you to determine your eligibility for insurance, underwrite and service your policy, and provide
other products or services. We collect the following types of information from you directly, from third parties, and when you
interact with us (such as when you visit our website, use a mobile application or email (collectively, our “Systems”).
• Information we receive from you on applications and other forms and communications in order to provide you with a
quote or insurance, service your policy (such as name, address, city, state, ZIP code, email address, telephone number, birth
date, household information, marital status, vehicle information, driver’s license number, social security number, property
information, information about your business, employer, occupation, education, previous insurance, and information about
beneficiaries).
• Information about your transactions with us, our affiliated companies, and other third parties (such as insurance
coverage information, claim information, premiums, and payment history).
• Medical information (such as information about your health status, treatment, payment for healthcare).
• Financial and payment information (such as income, credit card number, expiration date, and billing address).
• Information we receive from consumer reporting agencies, insurance-support organizations and other third parties
(such as driving records, creditworthiness, credit history or score, claim history, and vehicle data).
• Information that is automatically collected when you use our Systems, such as when you visit our website.
INFORMATION WE SHARE
We use and share your personal information as permitted by law.
• We may disclose information we collect from you (such as name, address, city, state, ZIP code, email address,
telephone number, birth date, household information, marital status, vehicle information, driver’s license number, social
security number, property information, employer, occupation, education, previous insurance, information about beneficiaries,
information about your business, medical information, and financial information).
• We may disclose information about your transactions with us, our affiliates, or others (such insurance coverage
information, claim information, premiums, and payment history).
• We may disclose information we receive from consumer reporting agencies, insurance support organizations, and
other third parties (such as such as driving records, creditworthiness, credit history or score, claim history, and vehicle data).
• We may disclose information that is automatically collected when you use or access our Systems.
• To the extent permitted by applicable law, we may also use, process, transfer, and store de-identified or anonymized
data about you for analytics, market research, testing, metrics, reporting, and other lawful business purposes.
PERSONS OR ORGANIZATIONS WITH WHOM WE MAY SHARE INFORMATION

As permitted by law, we may disclose information about you to:
• Our affiliated companies to market products and services to you.
• Companies that need the information to perform day-to-day normal business functions for us, such as marketing,
credit card processing, and website monitoring.
• Companies that help us determine your eligibility for insurance, issue policies, service your policy, or complete a
transaction you request.
• A financial institution with which we have a joint marketing agreement.
Page 11
• A financial institution with which we have a joint marketing agreement.

• Non-affiliated companies for their marketing and other purposes, with your prior consent.
• Other third parties as permitted or required by law, such as regulators, law enforcement or courts in response to a
subpoena, legal process, or inquiry, to prevent or detect fraud, to comply with legal requirements, or in connection with a sale
or transfer of our business.
HOW YOU CAN LIMIT SHARING

We do not share your information with nonaffiliated companies unless you expressly consent or such sharing is permitted by
law. You may consent to such sharing by the enclosed Consent Form and visiting us online at
https://privacychoices.confie.com/ or mailing to us at one of the following address:
Freeway Insurance Services America, LLC

ATTN: Customer Service Escalations Team
4630 Border Village Rd., STE 2018
San Ysidro, CA 92173
InsureOne Insurance Services Ameica, LLC

If a policy is issued to joint policyholders, we do not share information unless each joint policyholder consents. Even if you do
not consent, we may share your information with third-parties that perform business services for us or that assist us in
providing products and services to you or in fulfilling a request made by you, as described in this Privacy Notice or as
otherwise permitted by law.
You have the right to tell us not to share your information with affiliated companies for their own marketing purposes. You also
have the right to tell us not to share your information with non-affiliated companies with which we have agreements to jointly
market products. To tell us not to share, fill out and sign the enclosed form and mail it to us using the enclosed envelope, visit
us online at https://privacychoices.confie.com/, call us at 877-214-0149 toll-free, or send us a fax at 844-236-4345 toll free.
If a policy is issued to joint policyholders, then an opt-out by one policyholder will apply to all of the joint policyholders. If you
opt-out of such disclosures, it does not prohibit us from sharing your information with third parties that perform business
services for us or that assist us in providing products and services to you or in fulfilling a request made by you, as described in
this Privacy Notice or as otherwise permitted by law. We may share information if we do not hear from you within 45 days.
You have the right to tell us not to share consumer report information used for insurance eligibility purposes with our affiliates
for their own marketing purposes. To opt-out of such sharing, call 877-214-0149 toll-free. If you opt-out of such disclosures,
it does not prohibit us from sharing your information with third parties that perform business services for us or that assist us in
providing products and services to you or in fulfilling a request made by you, as described in this Privacy Notice or as
otherwise permitted by law.
Information we obtain from a report prepared by an insurance support organization may be retained by such organization and
disclosed to others.
MEDICAL INFORMATION
We will not disclose medical information about you without your express written consent or when required by law.
REVIEW AND CORRECTION

You have the right to review and to request correction of your information. To make a request, please send a written
request to us at one of the following addresses:

Page 12

InsureOne Insurance Services America, LLC

The request must include your name, address, policy number, and your notarized signature.
CONFIDENTIALITY AND SECURITY

We maintain reasonable physical, electronic, and procedural safeguards to protect your information. Only employees
who need information to provide products or services to you, or to perform business functions for us, will have access to it.
CHANGES TO THIS PRIVACY NOTICE

We reserve the right to modify this Privacy Notice at any time. If we make material changes, we will provide a
revised Privacy Notice. If we modify this Privacy Notice such that the use of your information is different from what was stated
in our Privacy Notice at the time the information was collected, we will notify you and you may have additional opt-out or opt-
in rights. Your information will be used in accordance with the Privacy Notice in effect at the time your information was
collected.
CONTACT US
For questions about this Privacy Notice or our information practices, please contact us at 877-214-0149 toll-free.
IMPORTANT PRIVACY CHOICES FOR CONSUMERS
You have the right to control whether we share some of your personal information. Please read the
following information carefully before you make your choices below.
Your Rights
You have the following rights to restrict the sharing of personal and financial information with our affiliates (companies we own
or control) and outside companies that we do business with. Nothing in this form prohibits the sharing of information
necessary for us to follow the law, as permitted by law, or to give you the best service on your accounts with us. This includes
sending you information about some other products or services.
Your Choices
Restrict Information Sharing With Companies We Own or Control (Affiliates): Unless you say “No,” we may share
personal and financial information about you with our affiliated companies.
(__) NO, please do not share personal and financial information with your affiliated companies.
Restrict Information Sharing with Other Companies We Do Business With To Provide Financial Products And Services: Unless
you say “no,” we may share personal and financial information about you with outside companies we contract with to provide
financial products and services to you.
(__) NO, please do not share personal and financial information with outside companies you contract with to provide financial
products and services.
Page 13
products and services.
Time Sensitive Reply
You may make your privacy choice(s) at any time. Your choice(s) marked here will remain unless you state otherwise.
However, if we do not hear from you we may share some of your information with affiliated companies and other companies
with whom we have contracts to provide products and services.
Name: Carlos Murguia
Account or Policy Number(s): GPSV-00166950-00
Signature: ___________________________________
To exercise your choices do one of the following:

(1) Fill out, sign and send back this form to us using the envelope provided (you may want to make a copy for your records);
(2) Call this toll-free number (877) 214-0149;
(3) Fill out, sign, and fax this form to us at (844) 236-4345 toll free; or
(4) Visit our website at https://privacychoices.confie.com/,
CONSENT TO DISCLOSE INFORMATION
By signing this form, I understand that I am consenting to the disclosure of my personal information to third-parties that are
not affiliated with Freeway Insurance Services America, LLC dba Cost-U-Less Insurance Center, SSB Insurance Services, Inc.
dba Seguros Sin Barreras Insurance Services, InsureOne Insurance Services Ameica, LLC dba Buschbach Insurance Agency,
dba Western Sage Insurance Agency, , dba California Insurance Specialists, dba Wm K Lyons Insurance Agency (the
“Company”). I understand that my consent will remain in effect until I revoke or modify it. I understand that I may revoke or
modify this consent at any time by contacting the Company at the address or telephone number below.
PRINT NAME: Carlos Murguia
ADDRESS: 3701 Branch St
DATE: 6/25/2021
SIGNATURE: _______________________________________
The Company will maintain a copy of this form and will provide a copy upon request. You may want to make a copy for your
records. You may revoke your consent at any time by contacting the Company at one of the addresses below or by telephone
at 877-214-0149 toll-free.

Page 14
InsureOne Insurance Services America, LLC

Page 15
Freeway Insurance Services America, LLC (California)

License #6002326
IMPORTANT CHOICES REGARDING YOUR MOTOR VEHICLE REPORT
In order for Freeway Insurance Services America, LLC (California). (“Freeway”) to provide me with a quote from the insurance
carrier(s), a certified Department of Motor Vehicle (“DMV”) printout of my Motor Vehicle Report (“MVR”) reflecting my driving
record and a printout of the Motor Vehicle Report (“MVR”) of any other drivers listed on my insurance policy (“Additional
Drivers”) is required. By signing below, I agree that Freeway can obtain my MVR and the MVR of Additional Drivers. The MVR
printout(s) may be provided by me as long as the following criteria are met: (a) the MVR is an official certified copy from the
DMV, and (b) the MVR is not older than 30 days from today’s date.
I understand I have the option to provide Freeway with an official certified MVR printout or Freeway can obtain this information
on my behalf and on behalf of any Additional Drivers. I understand there is a Document Storage/Imaging charge of $25.00. By
signing below, I also understand that Freeway may only use the MVR obtained on my behalf and on behalf of the Additional
Drivers for (a) underwriting purposes, or (b) for delivery to the insurance carrier(s), and is prohibited by DMV regulations from
giving me (or any Additional Drivers) a copy. I may obtain my own certified copy at any time by contacting the DMV. Please
note that an MVR obtained directly (printed) from the DMV website is NOT AN OFFICIAL CERTIFIED MVR.
Regardless of whether Freeway is able to obtain the MVR, I understand that I must disclose all violations and accidents
concerning my driving record and the Additional Drivers’ to the best of my knowledge on the insurance application. I further
understand that should the insurance carrier(s) that I am applying for coverage with discover any additional violations or
accidents concerning my driving record (or for any Additional Drivers), my policy may be subject to an increase in premium or
cancellation.
I have received and read the above notice, and I understand and agree to its provisions.
Client’s Signature: Date: 6/25/2021
SR-FILING ELIGIBILITY STATEMENT

(Sign only if applicable)
I understand that according to my MVR, I may not be eligible to obtain a valid license with the DMV. I have requested an SR-
Filing to be issued with my insurance policy and understand all fees are fully earned and non-refundable, even if I am not
eligible to obtain a valid license on the effective date of the policy.
I have received and read the above notice and I understand and agree to its provisions.
PAYMENT DISCLOSURE
Insurance premiums must be paid when due. To keep my policy in force, I must pay the Insurance Carrier the monthly
premium when due. If I do not send my monthly payment to the Insurance Carrier when due, I will lose my insurance
coverage. If my coverage is cancelled, a new down payment is required in order to replace the coverage. Furthermore, the
down payment I paid today does not include my next monthly payment.
Finally, I understand that, even if I do not receive a bill, it is still my responsibility to pay the premiums when due. If I do not
receive a bill, I must notify my broker or insurance carrier immediately. I can reach your Customer Service Department
by calling (800) 300-0227.
I have received and read the above notice, and I understand and agree to its provisions.
Page 16
Date: 6/25/2021
Household Member Disclosure
A driver should be listed on your automobile policy if they:

1. Live in the same household, have an active drivers license, and do not have an automobile policy of their own.
2. Use a vehicle on your policy on a regular or occasional basis regardless of whether they live in the same household or
not.
I, Carlos Murguia , do hereby represent that I have listed all drivers/operators of the insured motor vehicle(s) on the Carrier
Application, and all residents of my household (over the age of 14 and regardless of whether they drive the vehicle) on the
Carrier Application or Named Driver Exclusion document.
I agree to notify my insurance company of any new drivers and/or residents of my household (including those who have
since turned the age of 14) should changes occur during the term.
Address Verification Disclosure
The garaging location is commonly referred to as the location where the vehicle sleeps at night. If the vehicle stays at more
than one location during the year, the garaging location can be determined by how long the vehicle stays at each location.
Wherever the vehicle stays for the majority of the year, should be the garaging location.
I certify that the mailing and garaging addresses indicated on this application are true and accurate.
Furthermore, I agree to notify the Company of any changes of: (1) Resident Address, (2) Garaging Address of Vehicles insured.
NOTICE: FAILURE TO ACCURATELY DISCLOSE AND UPDATE GARAGING ADDRESS, DRIVERS AND HOUSEHOLD MEMBERS MAY
LEAD TO RESCISSION OF YOUR POLICY AND DENIAL OF ANY CLAIMS.
Applicant’s Signature:
Print Applicant’s Name: Carlos Murguia
Page 17
Additional Products CA
Initials ____ Hospital Indemnity

Hospital Indemnity coverage offers protection to the member or their family
(when a family plan is purchased) should they become hospitalized due to an
accident while riding or driving in any 4-wheel private passenger vehicle. It
includes AD&D Benefit for $5,000.
Initials ____ Identity Theft

Identity Theft Protection plan monitors your credit report and personal
information and alerts you of suspicious activity. Our ID theft plan also assists
with the costs of restoring and repairing a consumer’s identity and credit
history.
Initials ____ Telemedicine

A US doctor will diagnose you over the phone for common conditions and if
needed provide a prescription. Service is available to use 24 hours/7 days a
week. A $25 co-pay applies for each call.
6/25/2021
Customer Signature Date
Page 18
Universal Deal Checklist (AppOne)
Binding/Carrier Paperwork
 All carrier guidelines met.
 All required documents uploaded (driver’s license, registrations, proof of prior insurance, marriage, ITC, etc.).
 Where does the application need to be signed and/or initialed?
 File scanned within 2 hours.
 All paperwork scanned correctly. (If not, open a ticket and follow up with IT.)
 Carrier application properly bound with a policy number.
 Correct effective date on the application.
 Submitted amount—premium and applicable fees—uploaded correctly.
 Address, driver’s license, coverages, and vehicle(s) match in the carrier application, AppOne, and the Insurance
101-GCD Form.
 EFT agreement completed correctly. (Signature needed from bank account holder, not always same as policy
holder.)
 Added New Business Correction Form and proof of confirmation (if applicable).
 Uploaded or scanned ITC quote sheet (if required by state).
 Customer signature on any carrier endorsement for ride sharing (if applicable).
 Customer signature and proof of fax to carrier on any needed carrier driver exclusion documents (to prevent
cancellation).
 Uploaded exclusion form confirmation in operating system.
 Copies of the insured’s driver’s license and registration.
 Noted in system whether our customer is an in-store or phone sale.
FWY Paperwork
 All required FWY Forms are scanned and signed correctly. Includes:
 Privacy Notice, Household Member Disclosure, and Livery Ride Sharing Disclosure
 All other applicable forms (My Plan Coverage Checklist, Fee Disclosure Statement, Customer Receipt, SR-22
Disclosure Notice, Cancellation Request for policies being rewritten, Vehicle Inspection Form for Comp and
Collision, Quote Sheet, Driver Exclusion)
 Store customers only: All information on the Customer Profile correct, matching client information.
 Use scan cover sheet to confirm required documentation.
 ESign customers only: Check EchoSign document history confirmation.
CK/CC Barcode
 Funds collected at point of sale to cover submission amount (payment method and amount bridged correctly to
AppOne).
 Customer signature on Deferred Down Payment Agreement (hold credit card or promissory note, if applicable)
Photos
 Photos uploaded to AppOne (if required by carrier)
 Photos do not show existing damage, special equipment, or any other modifications.
 Uploaded signed Vehicle Inspection.
Proof of Ownership (VR)
 Uploaded proof of ownership (if required).
 Registered owners are excluded or rated per carrier guidelines (Vehicle, VIN, make, year, and model).
Additional Products
 Added NSD contract signed by the customer and seller.
 Customer info and amount collected match with payment receipt.
 NSD Membership number matches in operating system.
Producer Signature ____________________________________ Manager Signature _______________________________

Revision: 3/11/2021 Carlos Murguia eSign: 6/25/2021 3:18 PM PDT, IP: 2600:387:f:4b10::2
Freeway Insurance Services America, LLC – Sacramento-Broadway
4603 Broadway #B
Sacramento, CA 95820
Aspire General Insurance Services‐ CA Lic#: 0I10876

UNDERWRITTEN BY ASPIRE GENERAL INSURANCE COMPANY
Printed on 6/25/2021
PAYMENT RECEIPT
Policy Number GPSV-00166950-00
Amount Paid $189.83

Carlos Murguia
Payment Method Producer Trust
3701 Branch St
Sacramento, CA 95838-3429 Confirmation Number 4339011
Date/Time of Payment 6/25/2021 2:56 PM
Aspire General Insurance Company To make an immediate payment:

PO Box 2426 Online:
Rancho Cucamonga, CA 91729-2426 Go to www.agicins.com
Click on Make a Payment
Customer Service Pay by Phone:

(877) 789-4742 Call (877) 789-4742
customerservice@agicins.com Available for Credit Cards and Check Payments
www.agicins.com
Important Information
If your payment is returned or declined by your bank due to non-sufficient funds, stop payment or is otherwise invalid, your policy may be subject to
cancellation and a return item fee. Payments will be used to satisfy any balance due on previous policy terms.
Payments received on or after the cancellation date will be subject to a reinstatement fee, if the policy is eligible for reinstatement. If reinstatement payment
is made by check, draft, or other method of payment and that payment is returned for any reason, your coverage will be null and void and your insurance
coverage will cease as of the cancellation date on your Notice of Cancellation. Payments made on or after the cancellation date will subject your policy to
cancellation and if the policy has Triple Deductible, the Triple Deductible provision will apply for the first 60 days after the effective date of any reinstatement
with lapse or renewal with lapse.
Renewal payments received on or after the expiration date will be subject to a reinstatement fee, if the policy is eligible for reinstatement. If renewal
payment is made by check, draft, or other method of payment and that payment is returned for any reason, your coverage will be null, and void and your
insurance coverage will cease as of the policy expiration date. Payments made on or after the expiration date will subject your policy to cancellation and if
the policy has Triple Deductible, the Triple Deductible provision will apply for the first 60 days after the effective date of any reinstatement with lapse or
renewal with lapse.
.........................................................................................................................................................................................................
Thank you for choosing the path to Savings with Aspire.
GBL-064 (091714) S, 1, N, N, N, A

APPLICATION FOR INSURANCE
SAVINGS PROGRAM
Policy Information Policy Term & Policy Premium

Policy Number: GPSV-00166950-00 Effective Date: 06/25/2021 2:56 PM
Named Insured: Carlos Murguia Expiration Date: 06/25/2022 12:01 AM
3701 Branch St Transmit Date: 06/25/2021 2:56 PM
Sacramento, CA 95838-3429
Garaging 3701 Branch St

Address: Sacramento, CA 95838 Policy Premium Subtotal $2,085.00
Fully Earned Policy Fee $28.00
Home: (760) 590-5887 Mobile: (760) 590-5887 CA Fraud Fee $5.28
Work: Email: Other Fees $0.00
cutelove021117@gmail.com USA Auto Club Membership* $60.00
Policy Premium & Fee Total: $2,178.28
Broker: Freeway Insurance Services America, LLC – Sacramento-
Broadway
4603 Broadway #B
Sacramento,CA 95820
(916) 465-6300
Additional fees when applicable: Cancellation Fee $50,

Reinstatement $10, SR22 Filing $15, SR22 Reinstatement $25, Non-
Sufficient Funds $25, Endorsement $5, EFT/RCCP Installment $10,
Non-EFT Installment $14, Return Mail $5, Fraud Fee $0.88 per vehicle
semi-annual, Policy Fee $35
*If applicable, USA Auto Club Membership is your separate roadside

membership club and not part of your Aspire Insurance policy
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Driver Information
Yrs Intl/
Date of Sex/ Relation to DL#/ DL
Name Driving Other
Birth Marital Status Driver STATE Status
Exp Yrs
Carlos Murguia 1/10/1983 Male / Married Applicant D6929884 / Valid 22 0
California
Occupation: Work Address: ,
Rocio Ochoa 5/2/1986 Male / Married Spouse d5695298 / Valid 19 0
California
Occupation: Work Address: ,
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Vehicle Information: All vehicles on this policy must be garaged in the same residential location
# Year/Make/Model VIN# Usage Garaging Address
1 2003 GMC YUKON SLE/YUKON SLT 1GKEC13T33R164498 Pleasure 3701 Branch St

Sacramento California 95838
2 2003 Mitsubishi MONTERO SPORT XLS JA4LS31R13J013483 Pleasure 3701 Branch St
3 2015 Nissan VERSA S/S PLUS/SV/SL 3N1CN7AP9FL928262 Pleasure 3701 Branch St
--------------------------------------------------------------------------------------------------------------------------------------------------------------
Lienholder/Additional Interest
Vehicle: Lienholder/Additional Interest:
--------------------------------------------------------------------------------------------------------------------------------------------------------------
Coverages and Limits of Liability
V1 - 2003 GMC YUKON SLE/YUKON SLT Limit/Deductible Premium
Bodily Injury $15,000 / $30,000 $180.00
Property Damage $10,000 $270.00
Collision $500 $243.00
Comprehensive $500 $85.00
UMBI $15,000 / $30,000 $27.00
----------- ----------- -----------
Vehicle Subtotal $805.00
V2 - 2003 Mitsubishi MONTERO SPORT XLS Limit/Deductible Premium
Bodily Injury $15,000 / $30,000 $192.00
UMBI $15,000 / $30,000 $27.00
----------- ----------- -----------
V3 - 2015 Nissan VERSA S/S PLUS/SV/SL Limit/Deductible Premium
Bodily Injury $15,000 / $30,000 $140.00
Collision $500 $342.00
Comprehensive $500 $54.00
UMBI $15,000 / $30,000 $27.00
----------- ----------- -----------
Vehicle Totals $2,085.00
--------------------------------------------------------------------------------------------------------------------------------------------------------------
Underwriting Information Notes Y N
1 Do you own any other vehicle(s) not listed on this application? If yes, please explain and provide X
insurance policy number.
2 Are any vehicles used in your business or occupation? If yes please indicate the job/occupation X
duties below.
(Coverage is void during business or artisan use unless such use is indicated and acceptable by
Aspire General Insurance Company.)
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Occupation Information Notes Y N
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UNDERWRITING CERTIFICATION
Statement Under Penalty of Perjury:
I certify under penalty of perjury that the foregoing is true and correct:
1. The Insured Vehicle(s) will not be driven by employees.

2. The Insured Vehicle(s) will not be used to transport children/patients being cared for.
3. The Insured Vehicle(s) will not be used to transport flammable liquids, chemicals or explosive materials.
4. The Insured Vehicle(s) will not be used in Racing, Delivery (pizza, newspaper), Taxi service (Uber, Lyft, Zipcar), or Emergency Vehicle.
5. I understand and agree that coverage is void during business or artisan use unless such use is indicated and acceptable by Aspire General
Insurance Company.
6. All residents of your household 14 years and older, including roommates and all regular drivers of the vehicles, and all names currently
showing on the registration of any listed vehicle are either added to the policy or excluded from coverage.
7. All drivers such as children away from home or in college, who may operate your vehicle on a regular or infrequent basis are listed on this
application.
8. I understand that if any operator(s) job, occupation duties or occupancy changes, I agree to provide in writing the updated information.
I certify that all information provided above is true and correct, and that failure to provide correct information may result in denial or
cancellation of coverage.
XSignature of Applicant Date
-------------------------------------------------------------------------------------------------------------------------------------------------------------
ASPIRE GENERAL INSURANCE COMPANY ELECTRONIC DOCUMENT DISCLOSURE AGREEMENT
By accepting The Aspire General Insurance Company Electronic Document Disclosure Agreement, you consent and agree that we may provide
certain disclosures and notices to you in electronic form, in lieu of paper form. You retain the right to withdraw your consent for electronic
delivery. You may withdraw your consent at any time by giving us at least ten (10) days prior notice. Contact us by phone or by mail. Once
you have withdrawn your consent, we will then discontinue the online document service for the account and paper documents and notices will
be resumed. The cancellation of Online E-Documents in no way affects the validity or legal effect of all Online E-Document and disclosures
which have been previously delivered electronically under the Online E-Document Service.
-------------------------------------------------------------------------------------------------------------------------------------------------------------
ASPIRE GENERAL INSURANCE COMPANY COMMUNICATION AND TEXT MESSAGE AGREEMENT
I AGREE that representatives of Aspire General Insurance can call or text message me at the number provided on the application document
GPSV-002 even if I am on a federal or state do not call registry for any purpose, including marketing. There is no separate charge for this
service; however, your carrier’s message and data rates may apply. I agree that the calls and text messages may be generated using an
automatic telephone dialing system and may contain pre-recorded messages. I understand that consenting to receive calls or texts is not
required as a condition of purchasing any goods, services, or property.
By consenting, I agree that if I change the mobile phone number for which I am consenting to receive text messages, I will notify Aspire
General Insurance immediately of any such change in number. To stop receiving text messages, reply via text to 53987 with “STOP”. I
understand that following such a request to unsubscribe, I will receive a final message from Aspire General Insurance confirming that I have
been inactivated in our system. If you have any questions or need help, please contact customer service at (877) 789-4742 or email us at
customerservice@agicins.com

-------------------------------------------------------------------------------------------------------------------------------------------------------------
COMMERCIAL, BUSINESS, AND PROFESSIONAL USE EXCLUSION
I represent that the vehicle(s) listed on the policy to be insured by Aspire General Insurance Company is (are) NOT commercially, or in a
business or professional endeavor. I fully understand and agree that the insurance to be extended on the policy applied for shall not benefit
either the insured(s) or a third party claimant when the vehicles(s) for which coverage is requested is (are) used commercially, or in a
business or professional endeavor. I further understand and agree that there will be NO INSURANCE COVERAGE IN FORCE from Aspire
General Insurance Company on the policy hereby applied for if I, or any person using the vehicle(s) for which coverage is requested, am (is)
involved in an accident while using the vehicle(s) in the course of any commercial, business or professional endeavor.
--------------------------------------------------------------------------------------------------------------------------------------------------------------
NOTICE OF INSURANCE INFORMATION PRACTICES
If you have any questions concerning this policy or its coverages, please contact your producer. Your producer has a copy of your policy and
will be able to provide assistance to you.
-IN THE EVENT YOUR BROKER IS NOT ABLE TO ADDRESS YOUR CONCERNS IN A SATISFACTORY MANNER, YOU DO HAVE THE OPTION OF
CONTACTING THE CALIFORNIA DEPARTMENT OF INSURANCE TO ASSIST YOU.
California Department of Insurance
Consumer Services Division
300 South Spring Street, South Tower
Los Angeles, CA 90013
(800) 927-4357 (HELP)
Your Privacy and its Protection
In order to protect your privacy, we want you to be aware of the following information:
1. Personal information may be collected from persons other than you or individuals proposed for coverage.
2. If an investigative consumer report is ordered in connection with your insurance transaction, you will be given an opportunity to be
interviewed in connection with it. You also have the right to obtain a copy of the report. You may also personally review the report
by contacting the reporting insurance support organization.
3. I agree and understand that the Company will use electronic means to contact me for a variety of reasons, including, but not limited
to, when my policy cancels due to non-payment of premium or other lapse or expiration of the policy. I hereby authorize the
Company to contact me via any provided email address, home phone, cell phone, or other communication systems and authorize the
Company to email, SMS (I understand that carrier charges may apply), make automated dialer telephone calls to my cell phone or
land line, instant message me or otherwise contact me electronically.
4. You have the right of access and correction with respect to all personal information collected which is contained in our files.
5. Personal information and other privileged information collected by us or our brokers may be, in certain circumstances, disclosed to
certain parties without your authorization, as permitted or required by law.
Aspire General Insurance Company is concerned about the protection of your privacy. A more detailed description of our information
practices and your right to privacy is available at your written request.
--------------------------------------------------------------------------------------------------------------------------------------------------------------
ANNUAL MILEAGE SELF-CERTIFICATION FORM
Below is the estimate of the annual miles per vehicle that will be driven in 12 months following the inception of my Policy. I understand that
the Company will verify my commute mileage based on my garaging and work addresses provided on the application. This estimate will be
used to calculate my overall estimate of mileage. I may elect to change the estimate below and I understand that proof of mileage may be
required.
Vehicle Year/Make/Model Annual Miles Odometer
2003 GMC YUKON SLE/YUKON SLT 6000
2003 Mitsubishi MONTERO SPORT XLS 6000
2015 Nissan VERSA S/S PLUS/SV/SL 6000
POLICY ACCIDENTS/VIOLATIONS
The Following Accidents/Violations Will Be Charged. I confirm that I have no undisclosed driving activity
Driver Name Date Description Points Source

Carlos Murguia 11/26/2019 NON CHARGEABLE 0 ISO APlus
ACCIDENT (3P-60020)
--------------------------------------------------------------------------------------------------------------------------------------------------------------
APPLICANT’S CERTIFICATION
I agree all answers to all questions in this Application are true and correct. I understand, recognize, and agree said answers are given and
made for the purpose of inducing the Company to issue the policy for which I have applied. I further agree that ALL residents of my
household age 14 years or over, registered owners, as well as ALL operators who regularly operate my vehicles and do not reside in my
household, are shown above. I agree that my principal residence and place of vehicle garaging is correctly shown above and is in the state for
which I am applying for insurance at least 10 months each year. I understand the Company may rescind this policy if said answers on this
Application are false or misleading, and materially affect the risk the Company assumes by issuing the policy. In addition, I understand that I

have a continuing duty to notify the Company of any changes of: (1) address; (2) location of vehicles; (3) members of my household of
eligible driving age or permit age; (4) operators of any vehicles listed on the policy; or (5) use of any vehicles listed on the policy. I must
notify the company if I acquire a new or replacement vehicle within 3 days and understand there is no coverage for a new or replacement
vehicle after 3 days unless I specifically endorse the car to the policy and pay the premium for coverage. I understand the Company may
rescind this policy if I do not comply with my continuing duty of advising the Company of any change as noted above.
I understand and agree that in connection with my request for a premium quotation and Application for insurance: (1) the Company may
obtain consumer reports which may include a driver history report, or personal or privileged information from third parties; (2) such
information may be disclosed to affiliated or unaffiliated third parties without my prior permission but only as permitted or required by law;
(3) upon my written request, the Company will inform me if a consumer report was requested and the name and address of the consumer
reporting agency that furnished the report; (4) I may also request access to and correction of information the Company has collected on me;
(5) the Company may request and use subsequent consumer reports in updating and renewing any insurance afforded in connection with this
Application; (6) the Company will furnish a more detailed explanation of its information practices upon my request; and (7) refusal to
authorize the Company to obtain a consumer report may give the Company the right to decline insurance to me.
I hereby authorize the Company to obtain consumer reports on me. I agree the named members of my household and all other operators
listed under this policy have authorized me to consent on their behalf to all coverages provided herein and to authorize the Company to
obtain consumer reports on them for the rating and/or underwriting of the insurance for which I am applying and for any renewal thereof. I
agree to pay any additional premium owed if the amount of premium shown is inaccurate for any reason.
I have had the liability coverages and limits available for the purchase fully explained to me and have selected the limits shown on the
Application. I have had the different policy coverage levels available to me fully explained. I understand that coverage for Damage to a
Vehicle only applies when my vehicle is driven by a person listed on the Declarations Page. There will not be coverage under Damage to a
Vehicle if the person driving your vehicle is not listed on the Declarations Page. I made an informed decision and have selected the policy
coverage level shown on the Application.
I understand the policy may be rescinded and no coverage provided if my premium down payment or full payment is paid by check, credit
card, or debit card and the bank returns said check unpaid or fails to honor the credit charge or debit charge in full. I understand there may
be a processing fee imposed on any returned checks.
I understand processing fees may be included with my down payment and installment payments, and additional fees may be charged for late
payments. I understand my payments are first applied to the fees owed and then to the premium.
FRAUD WARNING: Pursuant to California Insurance Code Section 1879.2, you are hereby notified that any person who knowingly presents
a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fine and confinement in state prison.
WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an
insurance policy containing any false, incomplete or misleading information is guilty of a felony.
An insurer which refuses to provide coverage to an applicant who is a Good Driver must provide applicant with a written statement of the
reasons it denied coverage. In general, under California law, a Good Driver is a person who has not had more than one violation point or
more than one at-fault accident resulting in only Property Damage (in excess of $1000) in the last three years, or been convicted of driving
under the influence in the last 10 years.
I ACKNOWLEDGE, AGREE, AND UNDERSTAND THAT ONLY MINIMUM STATUTORY LIMITS IN THE STATE OF CALIFORNIA OF
$15,000 PER PERSON UP TO A MAXIMUM OF $30,000 PER ACCIDENT AND $5,000 IN PROPERTY DAMAGE WILL BE PROVIDED
FOR BODILY INJURY AND/OR PROPERTY DAMAGE resulting from losses due to the operation or use of a motor vehicle by persons other
than a named insured, a relative or a person listed as a driver on the declarations page with the express or implied permission of a named
insured or relative.
Note: Aspire General Insurance Company may have other programs available which a CA Good Driver may qualify for. Please contact your
Producer for a quote.
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PRODUCER'S STATEMENT: PLEASE READ CAREFULLY
I, the Broker, accept full responsibility for collecting, completing and obtaining necessary signatures on the application and all of the
supporting documents which will form a part of this application for insurance. I accept full responsibility for the storage of the signed
California Auto Insurance Application and all supporting documentation. These documents will be maintained by the Broker and available
for the periodic review by Aspire General Insurance Services.
For vehicles with physical damage coverages, I have identified all pre-existing damage on the Vehicle Inspection and I understand that I
am required to obtain and keep photos in my files. I understand that I will be required to provide copies, upon request of the damaged
areas.
For vehicles with physical damage coverages or vehicles with business/artisan use I understand that I am required to obtain and keep
photos in my files. I understand that I will be required to provide copies, upon request. (New vehicles written within 72 hours of purchase
only require a Window Sticker or Bill of Sale.)
I, the Broker will disclose to the applicant that any incomplete information gathered during the application process such as an incomplete
VIN and/or an undelivered MVR request, will be reviewed by underwriting and any discovered information may result in a premium
change, cancelation and/or declination of coverage.
To be rated as married, a person must share a common residence with their spouse and each must be listed or excluded on the policy.
Living apart; separated; and widowed are to be rated Single. I understand that the marriage certification must be completed, and proof of
marriage provided if applicable.
I understand International licenses must have never been licensed in the US. I have listed any violations/accidents, and collected signed
International Driver Certification and supporting documentation (document number is listed on this application), if applicable.
I understand all vehicles listed on this policy must be garaged in the same location, and the garaging address is listed on this application.
I have asked the applicant(s) all questions on this Application and these are the applicant(s) responses. To the best of my knowledge, all
of the information on this Application is true, correct and complete.
PRODUCER'S NAME: (Please Print) Freeway Insurance Services America, LLC Sacramento-Broadway
PRODUCER'S SIGNATURE: Date/Time:

Aspire General Insurance Services ‐ CA Lic#: 0I10876
Carlos Murguia
3701 Branch St
Sacramento, California 95838-3429
Named Driver Exclusion Endorsement
It is agreed that all coverages, including Uninsured Motorists coverage, afforded by the policy shall be null, void, and
of no effect while the automobile is being driven or operated by:
Excluded Driver Name Relation to Insured Date of Birth Driver License #

CALLIE DEPAUL Non Relative 6/10/1987
DANIEL HARRIS Non Relative 7/28/1986
THOMAS FOSTER Non Relative 1/22/1983
THOMAS FOSTER Non Relative 1/22/1983
If you have asked us to exclude any person from coverage under this Policy, then we will not provide coverage for
any claim arising from an accident or loss involving a covered vehicle or non -owned vehicle that occurs while
it is being operated by the excluded person. THIS INCLUDES ANY CLAIM FOR DAMAGES MADE AGAINST YOU, A
RELATIVE, OR ANY OTHER PERSON OR ORGANIZATION THAT IS VICARIOUSLY LIABLE FOR AN ACCIDENT
ARISING OUT OF THE OPERATION OF A COVERED VEHICLE OR NON-OWNED VEHICLE BY THE EXCLUDED
DRIVER.
The California Insurance Code requires an insurer to provide uninsured motorist coverage in each bodily injury
liability policy it issues covering liability arising out of the ownership, maintenance, or use of a motor vehicle. Those
provisions also permit the insurer and the applicant to delete such coverage completely or to delete such coverage
when a motor vehicle is operated by a natural person or persons designated by name. Uninsured Motorist coverage
insures the insured, his or her heirs, or legal representatives for all sums within the limits established by law, which
the person or persons are legally entitled to recover as damages for bodily injury, including any resulting sickness,
disease, or death, to the insured from the owner or operator of an uninsured motor vehicle not owned or operated
by the insured or resident of the same household. An uninsured motor vehicle includes an underinsured motor
vehicle as defined in subdivision (p) of Section 11580.2 of the California Insurance Code.
Signature of Applicant Date
GPSV-007 (052019) / ADVA-007 (052019) Carlos Murguia eSign: 6/25/2021 3:18S,

PM1, PDT,
N, N, IP:
N, A2600:387:f:4b10::2
P.O. Box 2426
Rancho Cucamonga, CA 91729-2426
(877) 789-4742  NAIC# 15290
www.agicins.com
GPSV-079 (02/2017)
Insured Name: Carlos Murguia Policy Number: GPSV-00166950-00
DELETION OF UNINSURED MOTORIST PROPERTY DAMAGE COVERAGE
The California Insurance Code requires insurers to offer coverage for damage to the insured motor vehicle, to the extent that you
are legally entitled to recover from the owner or operator of the uninsured motor vehicle, caused by an uninsured motor vehicle,
that either:
1. pays the collision deductible on the insured motor vehicle when you have purchased collision coverage; or
2. pays for the damage to the insured motor vehicle and shall not exceed the smaller of the actual cash value of the motor
vehicle or $3,500.
This rejection shall be binding upon every insured to whom the policy applies while the policy is in force and shall continue to be so
binding with respect to any continuation or renewal of the policy, or with respect to any other policy which extends, changes,
supersedes, or replaces the policy issued to the named insured by the same insurer or with respect to reinstatement of the policy
within thirty (30) days of any lapse thereof.
All other terms and conditions remain unchanged.
Signature of Named Insured Date
GPSV-079 (02/2017) S, 1, N, N, N, A

GPSV-029 (02/2017)
DEDUCTIBLE DISCOUNT ENDORSEMENT
In consideration of the premium charged, if you elect the Deductible Discount Endorsement,
you agree with us that this policy is amended as follows:
The following is added under PART III – DAMAGE TO A VEHICLE:
TRIPLE DEDUCTIBLE APPLIED DURING FIRST 60 DAYS AFTER POLICY INCEPTION, OR
REINSTATEMENT WITH LAPSE, OR RENEWAL WITH LAPSE, OR GAP IN COVERAGE,
OR ADDITION OF A VEHICLE.
The deductible listed on the Declarations Page is tripled if a loss occurs within 60 days of:
a. The inception of this policy; or
b. Reinstatement of this policy with a lapse; or
c. Renewal of this policy with a lapse; or
d. A gap in coverage; or
e. The addition of a covered vehicle. The triple deductible would only apply to a loss to
the added vehicle. The triple deductible does not apply to a loss if the added covered
vehicle replaces a vehicle listed on the Declarations Page.
f. The addition of Part III – Damage to a Vehicle to any vehicle that is currently listed on
the Declarations Page or was previously listed on the Declarations Page
For example, this means if you have a $600 deductible listed, and you have a loss within 60
days of any of these events, the deductible will be $1,800.
GPSV-029 (02/2017) S, 1, N, N, N, A

Carlos Murguia
3701 Branch St
PROOF OF MARRIAGE CERTIFICATION:
Name Marital Status Relation to Applicant
Carlos Murguia Married Applicant
Rocio Ochoa Married Spouse
CALLIE DEPAUL Single Non Relative
DANIEL HARRIS Single Non Relative
THOMAS FOSTER Single Non Relative
THOMAS FOSTER Single Non Relative
I represent that all married drivers on this policy are currently married.
X Signature of Applicant Date
Proof of marriage is required to be sent to underwriting when there is an excluded

spouse. Proof can be uploaded to the policy or sent to customerservice@agicins.com.
Proof of marriage is required to be maintained in broker's file on spouses with

different surnames.
GBL-009 (042020) S, 1, N, N, N, A
Aspire General Insurance Services‐ CA DOI Lic#: 0I10876
Printed on: 6/25/2021
Carlos Murguia
3701 Branch St
Authorization to Release Vehicle(s)
This Authorization to Release Agreement is made effective 6/25/2021. Vehicle(s) Covered by this Release:
Vehicle(s): 2003 GMC YUKON SLE/YUKON SLT 1GKEC13T33R164498

Vehicle(s): 2015 Nissan VERSA S/S PLUS/SV/SL 3N1CN7AP9FL928262
Pursuant to your policy under PART III – DAMAGE TO A VEHICLE - POWER OF ATTORNEY:
I, Carlos Murguia, hereby grant power, right and ability to Aspire and its employees, and assign the right to
release, move and transfer the above listed vehicle(s) on my behalf and without any additional communication
from me.
I hereby release the body shop, service center or other service provider of any liability for such release.
GPSV-033 (110314) S, 1, N, N, N, A

Aspire General Insurance Services, LLC ‐ CA DOI Lic#: 0I10876
AUTOMATIC MONTHLY PAYMENT AUTHORIZATION (EFT)
I authorize Aspire General Insurance Services to initiate scheduled deductions from the bank account identified below for payment of premium on the insurance
policy issued to me and any renewals thereof.
I authorize the financial institution identified by the routing number below to accept the post entries to the account.
I represent that I am the owner and/or an authorized signer of the account.
I understand that this authorization allows Aspire General Insurance Services to adjust the scheduled deductions to reflect any premium changes to my policy.
Aspire General Insurance Services agrees that it shall notify me in writing at least ten days prior to making any deduction if there is a premium change or seven
days if there is a due date change. Please note that although payment will typically be processed on the Withdrawal Schedule dates, please allow several days for
processing of the withdrawals from your account. Additionally, that Aspire General Insurance Services may electronically withdrawal or create a draft against your
account.
I understand that Aspire General Insurance Services will not send me a bill before scheduled deductions are made and that it is my responsibility to ensure
sufficient funds are in the account at the time of each scheduled deduction.
I also understand that my policy may cancel or expire if there are insufficient funds in the account, which could cancel this agreement and remove my policy from
automatic payment processing. In addition to any fees charged by my bank, Aspire General Insurance Services will charge a return item fee of up to $25.00 if my
payment is dishonored or returned for any reason. Additionally, you will be removed from the Automatic Monthly Payment Authorization program.
This authorization is to remain in full force and effect until Aspire General Insurance Services receives a written request from me to cancel my electronic payment
withdrawal or until Aspire General Insurance Services elects to cancel this agreement.
PLEASE NOTE THAT IF YOUR DUE DATE FALLS ON A WEEKEND OR HOLIDAY WE WILL MAKE THE PAYMENT ON THE NEXT BUSINESS DAY
FOLLOWING THE HOLIDAY/WEEKEND.
Please allow up to 7 days for changes or termination of electronic payment withdrawal to ensure changes are made prior to the withdrawal of your installment.
If you have any questions or concerns about this transaction, you can email customerservice@agicins.com or call Customer Service at (877) 789-4742.
All of the information requested below is required and very important for the accurate processing of your automatic monthly withdrawal payment plan. If any of the
information is missing or inaccurate, please be aware that this may delay the processing.
Please note that your monthly withdrawn payments are subject to change depending if any changes that cause an increase or decrease to your written premium
are made to the existing policy during the term.
Named Insured Carlos Murguia Policy # GPSV-00166950-00

Account Holder Carlos Murguia Cell: (760) 590-5887
Routing Number: 121042882 Home: (760) 590-5887
Account Number: 5114 Work:
Account Type: Checking
--------------------------------------------------------------------------------------------------------------------------------------------------------------
PLEASE ATTACH VOIDED CHECK HERE, CHECK REQUIRED
GBL-059 (082020) S, 1, N, N, N, A

Freeway Insurance Services America, LLC – Sacramento-Broadway
4603 Broadway #B
Sacramento, California 95820

Printed on 6/25/2021 2:56 PM

Carlos Murguia
3701 Branch St
AUTOMATIC PAYMENTS NOTICE - THIS IS FOR YOUR RECORDS
You have agreed and are currently set up on Automatic Payments from your bank or credit card. Your Minimum Amount Due will be automatically
withdrawn from your bank account on the Due Dates listed below. The charges will appear on your bank statement as “Aspire.”
If your payment is returned or declined for any reason, it will not be considered received for all purposes and the payment will be ignored with the
respect to all time frames, accordingly, return item fees will apply. Additionally, your policy may be subject to cancellation.
Please note that due to payment processing time, your transaction may not post to your account immediately. If your scheduled due date falls on a
weekend or holiday, your payment will be posted on the next business day.
You will not be receiving any further billing notices. Please keep this notice for your records.
As you have elected to have Electronic Funds Transfers withdrawn from your bank or Recurring Credit Card Payments, your policy now qualifies for
a reduced installment fee.
To make an immediate payment:

Pay by Phone
Call (877) 789-4742
Available for Credit Cards and Check Payments
SCHEDULE OF PAYMENT WITHDRAWALS

*Dates subject to change **Includes Installment Fee
Installment No Due Date* Minimum Amount Due**
1 7/25/2021 $190.80
2 8/25/2021 $190.80
3 9/24/2021 $190.80
4 10/25/2021 $190.80
5 11/24/2021 $190.80
6 12/25/2021 $190.80
7 1/25/2022 $190.80
8 2/22/2022 $190.80
9 3/25/2022 $190.80
10 4/24/2022 $190.80
11 5/25/2022 $190.45
..................................................................................................................................................................................................................................................................
Your policy is currently set up on Automatic Payments from your bank.
 Your Minimum Amount Due will be automatically withdrawn from your bank account on the withdrawal date.
 If you have any questions please contact Customer Service (877) 789-4742.
 To make a change to your Automatic Payments, seven (7) days notice prior to your Due Date is required.
GBL-020 (091714) Carlos Murguia eSign: 6/25/2021
S, 1, N, N,3:18
N, APM PDT, IP: 2600:387:f:4b10::2
2003
CALIFORNIA EVIDENCE OF LIABILITY INSURANCE CALIFORNIA EVIDENCE OF LIABILITY INSURANCE
This insurance complies with CVC 16056 or 16500.5 This insurance complies with CVC 16056 or 16500.5
Involved in an Accident? Call (855) 231-1727 Involved in an Accident? Call (855) 231-1727
Named Insured: Carlos Murguia Policy #: GPSV-00166950-00 Named Insured: Carlos Murguia Policy #: GPSV-00166950-00
Rocio Ochoa Rocio Ochoa
Effective Date: 6/25/2021 2:56 PM - Expiration Date: 6/25/2022 12:01 AM Effective Date: 6/25/2021 2:56 PM - Expiration Date: 6/25/2022 12:01 AM
Insurance Company: Aspire General Insurance Company Insurance Company: Aspire General Insurance Company
PO Box 2426 PO Box 2426
Rancho Cucamonga, CA 91729-2426 Rancho Cucamonga, CA 91729-2426
NAIC Code: 15290 NAIC Code: 15290
Year/Make/Model Vehicle Identification Number Year/Make/Model Vehicle Identification Number
2003 GMC YUKON SLE/YUKON SLT 1GKEC13T33R164498 2003 GMC YUKON SLE/YUKON SLT 1GKEC13T33R164498
Customer Service Assistance: (877) 789-4742 Customer Service Assistance: (877) 789-4742
2003
2003 Mitsubishi MONTERO SPORT XLS JA4LS31R13J013483 2003 Mitsubishi MONTERO SPORT XLS JA4LS31R13J013483
2015
2015 Nissan VERSA S/S PLUS/SV/SL 3N1CN7AP9FL928262 2015 Nissan VERSA S/S PLUS/SV/SL 3N1CN7AP9FL928262
GPSV-030 (040814) Carlos Murguia eSign: 6/25/2021 3:18 PM PDT,

S, 1,IP:
N, 2600:387:f:4b10::2
N, N, A
24 HOUR EMERGENCY TOWING
P.O. Box 660460  Dallas, TX  75266
First Name Last Name

Carlos Murguia Towing Assistance
Address
3701 Branch St 1-877-335-7897
City State Zip
Sacramento California 95838 Program ID: 15568
Effective Date Membership ID Producer ID:
6/25/2021 2:56 PM GPSV-00166950-00 Benefit: $50
Covered Vehicle(s) VIN(S) License
2003 GMC YUKON SLE/YUKON SLT 1GKEC13T33R164498
2003 Mitsubishi MONTERO SPORT XLS JA4LS31R13J013483
2015 Nissan VERSA S/S PLUS/SV/SL
3N1CN7AP9FL928262
…………………………………………………………………………………………………………………………………
This is not an automobile liability insurance contract
Welcome! Aspire General Insurance Services has arranged for United States Auto Club, Motoring Division, Inc.(“USAC”
or “We”) to bring you the best in roadside assistance services. We are dedicated to keeping you, our registered member
named above, on the road…safe, secure and smiling. This document outlines the benefits of your membership services.
Emergency Roadside Assistance Services
When you need roadside assistance, call our toll-free number and we will send help. This 24-hour number is the only one
you need to know. We will dispatch a service provider to you for the following services: towing, battery jump start, gas
delivery (up to 3 gallons), flat tire change, or locksmith service if you lock your keys inside your vehicle (the owner will be
required to present proper identification at the time lockout service is provided). We pay the service provider for covered
expenses, up to your benefit limit of $50 per incident. Emergency roadside service claims are limited to three (3) in any
twelve (12) month period.
Toll-Free Number
Simply call for all of your benefit and service needs. We’re here to help – 24 hours a day, 365 days a year. Any time you
need towing or have a question regarding your membership benefits or services, you can reach us by calling: 1-877-335-
7897
Note: As part of our continuing effort to maintain high quality service to our members, telephone calls between our
employees and our members are periodically monitored or recorded on a random basis by our supervisory personnel. By
accepting our services, you have indicated that you understand this and give your consent to any such monitoring or
recording regarding any telephone calls you may have with us.
Requirements for Coverage

You, the registered member, must be with the vehicle at the time of disablement and must provide proper identification
and proof of membership to the service provider upon request.
Items Covered
1. Service calls: delivery of gasoline (up to 3 gallons) lockout service (if you lock your keys inside your vehicle), battery
jump-start or flat tire change. (One service type covered within any seven (7) day period)
2. Towing of your disabled vehicle. (One tow covered within any seven (7) day period)
3. Members-only hotel and car rental discounts.
4. Theft reward benefit.
Items Excluded from Towing Services and Coverage:

1. Parts, replacement keys, labor, tire repair, rental or towing equipment, storage fees or any labor performed at a garage
or service facility.
2. Trucks over one-ton capacity, motorcycles, taxis, vehicles used for commercial purposes, camping or travel trailers,
mobile homes or any unit in tow.
3. Any form of impound towing or towing assistance by a private citizen, or someone other than a licensed service station.
4. Benefits and/or claims pertaining to roadside assistance submitted for direct payment or reimbursement will not be
covered if:
a) Towing results from an accident, vandalism, or fire as well as towing at the direction of a law enforcement
officer relating to traffic obstruction, impoundment, abandonment, illegal parking, or other violations of law.
GBL-074 (12012018) Carlos Murguia eSign: 6/25/2021 3:18 PM

D,PDT,
1, N, IP: 2600:387:f:4b10::2
N, N, A USAC1500612
2
b) Member fails to pay membership fees.

5. Vehicle which is not the Covered Vehicle.
Auto Theft Reward: United States Auto Club, Motoring Division, Inc. will pay a $5,000 reward for information leading to
the arrest and conviction of anyone who steals a member’s vehicle. Member, including family members and law
enforcement personnel are ineligible for this reward. The reward does not cover loss from vandalism or stolen contents
Hotel and Auto Rental Discounts: Member will need to call the toll free number for the hotel of their choice and provide
the discount number in order to receive the discount. United States Auto Club, Motoring Division, Inc. is not responsible
for making reservations.
HOTEL DISCOUNT NUMBER: 8000003475
Days Inn 1-800-DAYS INN Ramada 1-800-2-RAMADA Howard Johnson 1-800-I-GO-HOJO Microtel 1-800-771-7171 Hawthorn 1-800-527-1133
Knights Inn 1-800-843-5644 Travelodge 1-800-578-7878 Baymont Inn 1-877-BAYMONT Wingate 1-800-228-1000 Super 8 1-800-800-8000
Membership Agreement
This membership contract represents your agreement with United States Auto Club, Motoring Division, Inc. (USAC/MD)
and describes your benefits that are available in the United States. You will not be required to pay any sum in addition to
your membership fee for any service specified up to the benefit limit. Your membership begins on the date you are
enrolled. We may change your membership fee or benefits or services or cancel your membership upon prior notice to
you.
The following disclaimers apply to this agreement:

This is not an insurance contract.
This is not an automobile liability contract.
This is not an automobile liability or physical damage insurance contract, and does not comply with any
financial responsibility laws.
Emergency Roadside Assistance service providers are independent contractors and are not employees, agents,
or representatives of United States Auto Club, Motoring Division, Inc. and damage claims related to the service
provider will not be the responsibility of United States Auto Club, Motoring Division, Inc.
Address all inquiries about your benefits or services to:

United States Auto Club, Motoring Division, Inc., P.O. Box 660460 Dallas, TX 75266-0460
Staley Cash, President

United States Auto Club, Motoring Division, Inc.
List of Offices:
California Texas – Home Office Kansas Maryland– Incorp Services Inc.
5716 Corsa Ave, Suite 110 3410 Midcourt, Ste. 215. 3900 SW 40th Terrace 1519 York Road
Westlake Village, CA 91362 Carrollton, TX 75006 (800)348-2761 Topeka, KS 66610 Lutherville, MD 21093 (800) 246-2677
New Mexico Wisconsin Oklahoma Wyoming Nevada

1012 Marquez Pl, Ste 106-B 901 S. Whitney Way 613 SW 112th St 2510 Warren Ave 375 N. Stephanie St, Suite 1411
Santa Fe, NM 87505 Madison, WI 53711 Oklahoma City, OK 73170 Cheyenne, WY 82001 Henderson, NV 89014
GBL-074 (12012018) D, 1, N, N, N, A USAC1500612


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Payment Receipt 4603 Broadway Ste B

Carlos Murguia Customer #15348569

Total Fees: $320.00

Received Date Type Description Credit Card # / Check # / Other Amount

Customer Service: (800) 300-0227

Policy Number: GPSV-00166950-00 Insurance Company: Aspire General Insurance Services

Customer Signature: Agent Signature:

• Auto • Motorcycle • Home • Small Commercial Auto • Hospital Indemnity

• Renter’s • Identity Theft • Telemedicine

Ask your agent or call: 888-253-0674

Broker: Gabriela Rizo

Customer Name: Carlos Murguia

Carrier Name: Aspire General Insurance Services / ________

#GPSV- Aspire General Insurance

#GPSV-00166950-00 Aspire General

Submit Amount: $189.83

disciplinary action, up to and including termination.

INSURANCE 101 - GENERAL COVERAGE DESCRIPTION FORM

Selected Carrier: Aspire General Insurance Services/________

Vehicle 1: GMC YUKON Deductible $500

□ I decline all Comprehensive coverage.

Vehicle 1: GMC YUKON Deductible $500

□ I decline all Collision coverage.

Vehicle 1: GMC YUKON Limit N/A

□ I decline all Special Equipment coverage.

Vehicle 1: GMC YUKON Limit N/A

□ I decline all Rental Reimbursement.

Customer Signature: Date: 6/25/2021

Freeway Insurance Services America, LLC (California).

I will provide the indicated information on the date stated above.

AGREED TO BY : DATE: 6/25/2021

NAMED INSURED: Carlos Murguia

AUTHORIZED BY:________________________________ DATE: _____________________

MAIL Information to: FAX Information to:

CUSTOMER SERVICE TELEPHONE NUMBER (800) 300-0227

BROKER FEE DISCLOSURE FORM

This disclosure was prepared by the California Insurance Commissioner.

Freeway Insurance Services America, LLC (California).

BROKER FEE AGREEMENT

APPOINTMENT OF INSURANCE BROKER and AGREEMENT TO PAY BROKER FEE

Insured Name: _______________________________________________________________________________________________

For general customer service questions, please call (888) 300-0227

LIVERY (UBER – LYFT – RIDE SERVICE)

AND FOR-HIRE (DELIVERY/Pick-Up) DISCLOSURE

Signed and acknowledged this ____________ day of ___________, ______________

IMPORTANT PRIVACY CHOICES

Rev. June 2019

IMPORTANT PRIVACY CHOICES

PERSONS OR ORGANIZATIONS WITH WHOM WE MAY SHARE INFORMATION

• A financial institution with which we have a joint marketing agreement.

HOW YOU CAN LIMIT SHARING

Freeway Insurance Services America, LLC

InsureOne Insurance Services Ameica, LLC

REVIEW AND CORRECTION

Freeway Insurance Services America, LLC

4630 Border Village Rd., STE 2018

InsureOne Insurance Services America, LLC

CONFIDENTIALITY AND SECURITY

CHANGES TO THIS PRIVACY NOTICE

IMPORTANT PRIVACY CHOICES FOR CONSUMERS

products and services.

Time Sensitive Reply

Name: Carlos Murguia

AUTHORIZED BY:____________ DATE: _

Signed and acknowledged this ______ day of _, __________

Producer Signature ______ Manager Signature _